ROLE OF PHYSIOTHERAPY IN ICU

INTRODUCTION                                                                                                                                 

An Intensive Care Unit (ICU) is concerned with the management of the patient with acute life threatening condition within the specialised environment of ICU.

Thus ICU can be defined as the services for the patient with recoverable diseases who can benefit from a detailed observation and treatment than is generally available in the standard ward and department.

Critically patient in ICU suffer long-term physical and psychological complications. They are on long term mechanical ventilation, which leads to the 90% of long-term ICU survivors will have significantly muscle weakness. Prolonged stay in ICU are also associated with impaired quality of life, functional decline, cost of care, etc.

Therefore, they require a multidisciplinary team to work with the assessment and management of respiratory complications, physical deconditioning, neuromuscular and musculoskeletal conditions.

Physiotherapy is an important part of this multidisciplinary team to promote lung function, reducing the incidence of ventilator-associated pneumonia, facilitating weaning off and promoting early discharge from the ICU.

ICU APPARATUS                                                                                                                                    

The ICU should have the following equipments in case of emergency:- tracheal incubator,difibrilator, bronchoscopy, chest drainer, IABP (Intra Aortic Balloon Pumping), Invasive haemodynamic monitoring, Suctioning equipment, pharyngeal airways(artificial), mechanical ventilator, Ambubag, etc.

ICU STAFF                                                                                                                                                

A 1:1 nurse: patient ratio is required i.e. 1 nurse is available for one patient 24 hours. 

Medical doctor who is also known as RESIDENT.

Senior resident (SR)

administrative staff 

Other health care professionals like Physiotherapist, Dietician, Pharmacist, Lab technician, Social workers, etc.

PATIENT SELECTION AND LIMITING TREATMENT                                                                    

Patient selection is important to ensure a human approach to manage the critical ill patient and to use the limited resources appropriately.

The decision is done on some ethical principle:-

      --The first objective is to preserve life.

      -- Do not harm

      -- Respect autonomy of the patient.

      -- Allocate medical resources carefully

      -- Tell the truth

DOCUMENTATION IN ICU                                                                                                                    

Regular systemic clinical assessment of the patient is recorded.

It includes-- vital signs, haematological, biochemical and microbiological investigation, treatment plan, drug regime, clinical signs, etc.

PRIMARY CONCERN IN ICU                                                                                                                

-- Acid- base balance

--fluid electrolyte status

-- haemodynamic status

--ECG monitoring

-- ventilator monitoring

-- EEG and ICP monitoring, etc.

SECONDARY CONCERN IN ICU                                                                                                         

-- Arterial B.P.

-- Systolic B.P and Diastolic B.P.

-- Mean pressure ( difference between diastolic and systolic B.P., should not exceed 40)

-- Temperature

-- Heamoglobin concentration

-- Urine output

-- Blood volume, plasma volume, red blood cell count

-- Central venous pressure (CVP)

-- Pulmonary artery pressure and pulmonary capillary wedge pressure

-- Cardiac output

--Transcutaneous oxygen and carbon dioxide tension.

--Pulse oximetry, etc.

COMPLICATIONS IN ICU                                                                                                                      

COMPLICATION OF ARTIFICIAL AIRWAYS:-

👉 Damage to the nasal passage or lips-   During insertion, facial trauma or trauma to the nasal structure or lips may occur. While in place, lip ulceration,necrosis of soft tissues, erosion of the nasal septum, increase resistence from the smaller tubes.

👉Damage to the Oropharynx- Soft tissue damage to the Oropharyngeal, retropharyngeal and hypopharyngeal may occur.

👉Damage to the larynx and trachea  Soft tissue damage, laryngospasm, laryngeal muscles inflammation and tracheal injury, tracheal dilation may occur.

COMPLICATIONS OF PROLONGED IMMOBILISATION:-

The immediate effect of immobility are associated with cardio-pulmonary and musculo-skeletal changes in 24-48 hours.

The systemic effects are more pronounced in premature infants, young and older people, smokers, obese, etc.

👉 The changes in cardiovascular system are-

      Fluid volume redistribution

      Decrease in total heart and left ventricular volume.

      Increase in haemocryte and haemoglobin.

      Venous stasis

      Increased chances of venous thrombosis, thrombo-embolism

     decreased hydrostatic tolerence

     decreased VO₂ max.

👉 The changes in musculo-skeletal system are-

     muscle inactivity

     loss of muscle mass

     loss of muscle endurance

     loss of muscle strength.

PSYCHOLOGICAL COMPLICATION IN ICU:-

Confusion, lethargy, less responsiveness, sleep disturbance, loss of privacy, mobility, speech difficulty, disorientation of time and place, etc.

NUTRITIONAL COMPLICATIONS IN ICU:-

In ICU, patient does not receive proper diet hence can have some nutritional deficiency.

SKIN COMPLICATION IN ICU:-

Pressure sores, ulcers, gangrene, etc

Other complications:- 

Pulmonary aspiration, barotrauma, cardiopulmonary arrest, hypoxemia, cardiac arrhythmia, cervical spinal cord injury, communication problems, decreases mucous transport, ineffective cough, etc.

SHORT-TERM GOALS OF PHYSIOTHERAPY                                                      

👉Both passive and active exercises to maintain the muscular integrity.

👉 Positioning of patient is done to allow gravity to help in draining the sputum from the lungs.

👉 Manual techniques like shaking and vibration to loosen and clearance the secretion of lungs.

👉 Suctioning is done to clear the secretion.

LONG-TERM GOAL OF PHYSIOTHERAPY                                                          

Physiotherapist plan an extensive rehabilitation program to integrate and re-initiate the patient in the society.

BRRUNSTORM'S APPROACH, EASY AND IMPORTANT NOTES, VERY EASY TO UNDERSTAND

                               BRUNNSTORM'S APPROACH

INTRODUCTION

It was developed by Signe Brunnstorm, a Swadish American physiotherapist. It is a neurophysiological treatment approach, that has been conceptualised from two important theories of motor control namely- a)Reflex Control Theory     b)Herarchial Control theory

a) Reflex Control Theory:- In this theory, reflexes are the building blocks to complex motor control and movement.It says that afferent sensory inputs are necessary prerequisite for efferent motor output. We can understand this by an example:- In acute hemiplegic patients, at day 1 or day 2, there is no movement or flaccidity, there is no reflex activity or no movement. In this situation, brunnstorm states that we should first utilise techniques which will facilitate and use reflex to regain motor control in hemiplegic patients.

b)Hierarchial Control Theory:- It states that CNS is organised in hierarchy levels to control motor functions of the body.

PATHOPHYSIOLOGY

*In normal individual, the motor response of the mid brain, brainstem and spinal cord are controlled by the higher centers (cortex).

*Certain motor behaviours at subconscious and reflexive levels are processed at spinal cord, brainstem and mid-brain level.

*Stroke appears to result in development in reverse, recovery of voluntary movement post stroke proceeds in sequence --  

      - first the therapist should try to facilitate reflexive movements that are mediated by brainstem and spinal cord.

     -followed by more complex movements that are mediated by mid-brain. (flexor synergy, extensor synergy)

      -once the patients gain control over these synergies, then brunnstorm recommends now we should progress towards producing more complex motor behaviour which are mediated by higher centers (cortex).

*Proprioceptive and exteroceptive stimulus can be used to evoke desired motor or toner changes

* Progress the patient from lower to higher motor center.

BASIC LIMB SYNERGIES 

Limb synergies are intensive of associative reaction. They may occur either reflexively or as early stage of voluntary control when spasticity is present.

 When the patient initiates movement at one joint, all the muscles that are linked in synergy with that movement automatically contract causing stereotypyped movement pattern.                                           

Hemiplegic patient cannot perform isolated movements when they are bound by any synergy, example:- a hemiplegic patient wants to flex his elbow, then he won't be able to do it without producing scapular retraction and elevation and shoulder abduction. So everytime he want to flex the elbow, he will be accompanied by activation of rest of muscle of this synergy.                                          

                                -: UPPER-LIMB SYNERGY:-

-:FLEXOR SYNERGY    

 -: EXTENSOR SYNERGY

-: MIXED SYNERGY

                                1. FLEXOR SYNERGY

                                        2. EXTENSOR SYNERGY

          

                                        3. MIXED SYNERGY

                                      -: LOWER LIMB SYNERGY

-:FLEXION SYNERGY

-:EXTENSOR SYNERGY

-: MIXED SYNERGY

                                                 1.FLEXOR SYNERGY

                                                    2. EXTENSOR SYNERGY

                                                  3. MIXED SYNERGY

Amputation (Causes, level) along with its Physiotherapy management

 Defination:-  

 Removal of limb, partly or totally, from the body, is termed as Amputation. Disarticulation is removing the limb through a joint. 

Indication:-

Level of Amputation:-

In a limb, an amputation is carried out at a level which will give the stump an optimum length to facilitate prosthetic fitting. The level of amputation is determined by the viability of the tissues. However, it is important that the stump should have a well-healed, non tender, supple scar.

UPPER EXTREMITY

👉 Forequarter amputation - Also known as scapulothoracic amputation. It is carried out proximal to the shoulder joint. In this type of amputation, part of scapula and clavicle are removed along with the shoulder girdle muscles.
👉 shoulder disarticulation- It is the removing of shoulder joint, but is generally not so popular.

👉 Above- elbow amputation- Also known as Transhumeral amputation. A 20-cm-long stump from the tip of the acromion is measured.

👉 Below-elbow amputaion- Also known as Transradial amputation. The optimum length of the stump is 20cm from the tip of olecranon.

 👉Krunkenberg amputation:- In this, the forearm is split between the radius and ulna to provide the pincer grip. The patient can hold a spoon or lighter objects with this 'fork'. 'Hook' prosthesis can be put over this stump for cosmetic purpose.

👉Amputation through the hand:- In this, many forms of amputation are performed through the hand i.e. through metacarpals, etc.

LOWER EXTREMITY

👉 Hindquarter amputation:- Also known as Transpelvic amputation. In this, part of pelvis is removed along with the lower extremity.

👉 Hip disarticulation:- The femur is removed from the acetabulum is performed.

👉 Above knee amputation:- Also known as transfemoral amputation. The optimum length of the stump is about 25-30 cm measured from the tip of the greater trochanter.

👉Knee disarticulation:- It can be performed through the knee as well but not acceptable cosmetically.

👉Below knee amputation:- Also known as transtibial amputation. It is most commomly performed amputation. In this, the optimum length is 14 cm from the tibial tubercle. A patellar tendon bearing (PTB) prosthesis can be fitted over the stump of adequate length.

👉Syme's amputation:- In this operation, the tibia and fibula are divided just above the ankle joint then the skin over the heel is attached back to the stump end of the stump with or without calcaneum.

PHYSIOTHERAPEUTIC MANAGEMENT OF THE AMPUTEE 

Physiotherapy plays the most significant role in the management of an amputee from the time the surgeon decides for amputation till the patient is back to his work.

The basic approach of physiotherapy is to establish a new proprioceptive system.

The management is divided into three stages:-

i) Preoperative stage

ii) Early postoperative stage

iii) Mobility stage

1. preoperative stage:-

Assessment:- The physiotherapist has to assist  the ROM, muscle power, Condition of the skin, status of circulation and sensation, the status oh hearing and vision.

:- Assessment of the psychological status is extremely important as losing a limb can produce psychological trauma which can lead to depression.

:- besides these, it is also important to know the environment of the patient's home and his working place.

Preoperative training:- The aim of the preoperative training is to prevent the complications of the postoperative phase. 

:- teach breathing techniques, isometrics of the muscles, positioning and mobility, balance, equilibrium,walking techniques.

:- the patient should also be educated to take care of the pressure points and about the phantom pain

Reassurance:- Psychological reassurance can be done by practical demonstration by the patient who has undergone same surgery.

2. Early postoperative stage:-

☺Breathing exercises which were taught preoperatively are done to prevent any chest complications.

☺There are more chances of developing contracture (adduction and rotation) so to prevent this, the patients limb should be positioned correctly all the time i.e. any position which can develop contracture should be avoided.

☺The patient should be encouraged to move in the bed by pushing up the body on the arms. Vigorous ROM and strengthening exercises should be given for whole body.

After 3-4 days of surgery, the stump exercises can be initiated in pain free range.

Management of the stump

TO CONTROL STUMP OEDEMA

Stimulation with limb in elevation with the elastic bandage.

Resistive exercises to the stump and the rest of the joints.

Stump bandaging and conditioning  play an important role in conditioning and shaping of the stump.

PRINCIPLES OF BANDAGING THE STUMP

The pressure of the bandage should be moderatively firm and evenly distributed, decreasing proximally. Extra pressure is necessary over the corners to obtain a conical shape of the stump.

STUMP HYGIENE

The regular washing of the stump with warm disinfected soap water and thorough drying.

3. Mobility stage:-

This is the stage of mobilisation and restoration of functional independence. 

It starts with crutch walking. (It has been observed that patient tend to walk on crutches holding the stump in flexion, it should be avoided.)

Walk in parallel bar with both arm support  ↣  ↣  ↣   ↣ Walk in parallel bar with one hand support 

Frozen Shoulder ( causes, symptoms, stages, physiotherapy management)

 WHAT IS FROZEN SHOULDER?

Frozen shoulder is a condition that affects the shoulder joint. It is also known as Adhesive Capsulitis. It is an inflammatory lesion of glenohumeral capsule leading to healing of contracture, results in loss of volume of joint. It usually involve pain and stiffness that develops gradually, get worse and then finally goes away. This can take from a year to 18 months or sometime 3 years.

The shoulder is made up of basically 3 bones, i.e. humerus, scapula and clavicle. There is also a tissue surrounding the shoulder which holds everything together means stabilises the shoulder joint and this is called Capsule.

In frozen shoulder, this capsule becomes so tight and thick that makes the shoulder movements very difficult.

STAGES OF FROZEN SHOULDER:-

1. FREEZING STAGE:-

   💧 All the AROM and PROM are painful at extreme of range and pain is elicited over pressure.

   💧 It slowly get worse over time and may hurt more at night.

   💧 This can last for approximately 6-9 months

2. FROZEN STAGE:-

   💧 Pain decreases in this stage but stiffness increases as there is adhesion formation and contracture of capsule.

   💧 Patient complaints of performing ADLs such as combing, dressing, reaching the back pocket.

   💧 This stage lasts for 4-12 months.

3. THAWING STAGE:-

   💧 Range of motion starts to go back to normal

   💧 This can take around 1 year to 18 months.

  

👉 Frozen shoulder is self-remitting condition in which the symptoms vanish completely in 18 months of time.

CLINICAL FEATURES OF FROZEN SHOULDER:-

👉 Patient complains of pain in the lateral brachial region (V of deltoid) refers to C₅ and C₆ segment.

👉 The pain describes by the patient is dull ache only on activities and on when you unconsciously lie on the same side.

👉 On physical examination the movement is restricted in Capsular pattern ( EXTERNAL ROTATION IS MORE LIMITED THAN ABDUCTION WHICH IS MORE LIMITED THAN INTERNAL ROTATION)

👉 Difficulty in performing BADLS and ADLS.

SPECIAL TESTS

SCARF TEST 

In this test, horizonal adduction and flexion are checked by asking the patient to reach superior border of opposite scapula from the front of the chest. If patient is not able to perform this, then the test is POSITIVE.

SHOULDER SHRUG SIGN

In this, the patient will not be able to lift the arm to 90 degree abduction without elevating the whole scapula or shoulder girdle. 

APLEY'S SCRATCH TEST

The patient is asked to touch the superior border of scapula by abduction and external rotation or by adduction and internal rotation.

MANAGEMENT OF FROZEN SHOULDER:- 

Patient education:- For treatment of frozen shoulder, patient education is very important in helping to reduce frustration and encourage compliance. It is also helpful to create Home Exercise Program which can treat the condition more early.

Physiotherapy management will depend upon the stage--

       1. ACUTE PHASE  

Relief of pain and spasm is the main focus of this stage, which is controlled by application of ice pack, ice massage, TENS.

During this stage, any activity that can cause pain should be avoided. Better results have been found in patients who performed simple pain free exercises, rather than intensive physical therapy.

A pulley may be used to assist range of motion, depending on patient's ability to tolerate the exercise.

Isometric strengthening of rotator cuff muscles, pendulum exercises are performed .

2. SUBACUTE PHASE

U.S is given to break the adhesion in capsule which is given into posteroinferior area.

Gentle and specific shoulder joint mobilisation and stretches are performed to regain range and strength of the joint.

Mobilisation with movement (MWM) appears to be most effective and more effective than stretching exercises alone.

Care must be taken not to introduce exercises that are too aggresive.

    👉 capsular stretches are performed (anterior , posterior and inferior stretches)

3. CHRONIC PHASE 

Strengthening exercise are also included along with the progression of all the above exercises.

The stretch can be held for longer duration and sessions per day can also be increased. 

Pulley and WAND exercises are also introduced in the treatment programme.

Home Exercise Program is given to the patient to reduce the chances of relapsing of the condition.

      

  

MCKENZIE METHOD

                                                      INTRODUCTION

McKenzie method is a technique used in physical therapy. It was developed by Robin Mckenzie, a New Zealand. This is also known as Mechanical diagnosis and therapy(MDT). It is a system comprising of assessment, diagnosis and treatment for the spine and extremities. 

In this, the physiotherapist finds out the relationship between causes, effects and the positions of the patients he assumes while sitting, standing or moving, and the location of pain as the result of these positions or activities.

So this approach requires the patient to move through a series of activities and tests movements to elicit the patient's pain response. Then therapist uses these information to develop an exercise program to reduce the pain.

                                                              AIMS

                          👉 Reducing pain

                          👉 Centralisation of symptoms

                          👉  Complete recovery of pain

                                                       STEPS

1. ASSESSMENT:- In this step, the therapist takes the history of the patient, checking the pain aggrevating and relieving positions and also rules out the RED FLAG SIGNS.

                                      *RED FLAG SIGNS like anorexia, weight loss history, presence of night pain and ON/OFF fever.

2. TREATMENT:- This is based on assessment and it varies from person to person. The therapist teaches the patient that positions which can relieve his pain.

3. PREVENTION:- This step is done to minimize the reoccurence of the conditions. It tells the patients about the factors and causes that will aggrevate the pain.

                                                    MCKENZIE CLASSIFICATION

                                       👉 POSTURAL SYNDROME:-  This is basically  due to attaining the wrong posture for longer period of time. Pain subsides after changing the posture. It is common in younger age group(below 30 years). The cause is the overstretching of the normal tissues because of poor sitting or standing postures or lack of stretching exercises in sedentary professions.

                                      👉 DYSFUNCTION SYNDROME:- This is caused by mechanical deformation of soft tissues affected by adaptive shortening. Pain is produced as shortened structure are stressed by end range.

                                     👉 DERANGEMENT SYNDROME:- In this, anatomical disruption or displacement occurs within the intervertebral disc. In younger age group, there is displacement of the annulus complex or fluid nucleus, whereas in older age group degenerated annulus or fibrosed nucleus may be present.

                                                DIRECTIONAL PREFERENCE

It describes the situation when movements in one direction will improve pain and limitation of range, whereas movements in opposite direction cause sign and symptoms to worsen.

    👉 CENTRALISATION:- In this, limb pain emerging from the spine is progressively abolished in a distal to proximal direction in response to treatment.

  👉 PERIPHERILIZATION:- Pain emerging from spine spreads distally into the limb by the treatment. If this occurs, the treatment strategy should be avoided.

                                                               TREATMENT

The treatment plan of Mckenzie depends upon the categorisation of symptoms.

          If patient has symptoms of postural syndrome, correction of position is the treatment of choice. The patient is advised to follow correct ergonomics, attaining good posture for sitting, standing, lifting. Postural correction involves stretching of contracted structures, strenghening of weak muscles, correction of malalignment with manipulation.

          If patient has symptoms of dysfunctional syndrome, treatment includes Mckenzie extension exercises to prevent the progression of the symptoms.

         If patient has derangement syndrome, then extension protocol doesn't improve symptoms therefore core stability exercises play an important role.

                                                                                        

                                 

Female Athlete Triad

                                                          INTRODUCTION

The female athlete triad is a medical condition observed in physically active females. There are 3 components in FAT:-

                   💧Osteoporosis

                  💧 Amenorrhea

                  💧 Eating disorder

It is important to note that all the components of the triad are NOT needed to triad to be present.

Timely prevention, recognition and treatment can delay the progression.

In this diagram, red triangle shows the triad conditions and green triangle shows normal parameters.

                                   1. OSTEOPOROSIS

It is a major health problem. It can be defined as low BMD (Bone Mass Density). This lead to bone fragility and recurrent bone fractures.

CAUSES:-      1. Reduced Ca²+ absorption from intestine

                                          ￬

                     Parathyroid gland activated

                                        ￬

               Parathyroid hormone is released

                                      ￬

        increases resorption of calcium from the bones

                                     ￬

                        decreased BMD

    2nd reason can be Postmenopausal oestrogen deficiency ( which will lead to decreased calcium absorption)

COMPLICATIONS:-  frequent fracture (most commonly hip and wrist)

                                  :-  fall risk increases

                      2. AMENORRHEA

Menstrual function ranges from enumenorrhea (menstrual cycle 28 +7/-7 days) to amenorrhea ( absence of menstrual cycle for >90 days). It may be primary ( 1st menustral cycle is delayed) and secondary ( when menstral cycle has begun).

CAUSES:-  It can be due to weight loss, stress, excessive or wrong exercises.

                   3. EATING DISORDERS

 There has been a relationship between eating disorder and athletic activity. There are some sports in which the emphasis on thinness and reduction in body fat like gymnastics, ballet dancing, etc. Pressure from coaches, parents or competitors regarding body shape may lead to abnormal eating pattern. Other psychological risk factors like low self esteem, anxiety and OCD. 

Eating disorder can be: i) restrictive eating pattern                                                                                                                          ii) classic eating disorder like anorexia nervosa (fear of being overweight) and   bulimia nervosa (binging followed by avoid weight gain.

                 SYMPTOMS OF FAT

Absent or abnormal periods, acne, bone loss, excessive facial hair, fatigue, hair loss, headache, pelvic pain, vision changes, weight loss.

                TREATMENT OF FAT

Female athlete triad is a serious disorder and requires treatment. The main goal of the treatment is to normalise the menstrual cycles and to improve bone density.

Diet and Exercises:

The doctor would discuss the patient’s eating habits and suggest changes to improve nutrition in order to meet body requirements. The patient exercise routine is also revised to maintain healthy body weight.

Medications:

• The doctor would prescribe hormonal therapy to treat amenorrhea. Usually oestrogen and progesterone are prescribed to treat the altered menstrual periods. These hormonal medications also help to improve bone health.
• After evaluating the patient, the doctor would prescribe calcium and vitamin-D supplements to prevent bone weakness.
• However, the patient requires support from doctor, coaches and other family members for successful treatment of this condition.

Psychological Management:

It is one of the most important yet underutilized management strategies for this condition Patients with female athlete triad are often very competitive people and changing their mentality is not very easy. Psychological counselling is required for managing patient behavior. Mental health intervention is more important in patients with established eating disorders such as anorexia nervosa or bulimia nervosa.

                                    

                                    

                                                 

IMPINGEMENT SYNDROME

 INTRODUCTION:- Impingement is the inflammation produced by the injury of rotator cuff muscles around coracoacromial arch. It occurs mostly in throwers and patient comes with the chief complaints of having difficulty in performing overhead rotational movement.

CAUSE:- The cause of impingement can be -

 i) supraspinatus tendonitis

ii) bicipital tendonitis

iii) coracoacromial bursitis

iv) calcification in any of above tendons leading to tear.

v) hook type of acromion.

CLINICAL FEATURES:- The patient generally fall in the age of 40-60 years. ROM of forward flextion and abduction is restricted beyond 100 degree in internally rotated position. Effusion may or may not be present. Instability may or may not be present.

SPECIAL TESTS:- 

  -: PAINFUL ARC TEST:-

Purpose of Test-  To test for the presence of subacromial impingement.

Test Position- Sitting or Standing

Performing the Test-  In this, the patient is asked to elevate (either flexion or abduction) the arm. The test is considered POSITIVE if the patient has pain in between 60-120 degrees of the movement.

  -: NEER'S IMPINGEMENT TESTS:-

Purpose of the Test- This test is designed to reproduce symptoms of rotator cuff impingement.

Test Position- Sitting or Standing

Performing the Test- In this, the examiner elevates the patients arm in internally rotated position. Pain is produced which will indicate overuse injury to the supraspinatus muscle or biceps tendon.

-: HAWKIN'S KENNEDY TEST:-

Purpose of the Test- For the presence of any impingement of the rotator cuff muscles

Test Position- Sitting or Standing

Performing the Test- The examiner places the patient's arm shoulder in 90 degrees of shoulder flexion with the elbow flexed to 90 degrees and then internally rotates the arm. The test is considered POSITIVE if the patient feels pain with internal rotation.

*To rule out the supraspinatus tendonitis cause of the impingement syndrome. We use EMPTY CAN TEST.

             In this, the patient is supposed to perform abduction in scapular plane with the thumb pointed downward. Such patient will have pain in the initial range of this movement.

*If the cause of impingement is involvement of biceps brachii. We use two tests:

 1.  SPEED'S TEST- The patient attempt to perform resisted elbow flexion and forward flexion of arm with supinated hand.

2. YERGASON'S TEST:- In this, resisted supination is performed with flexed elbow.

     

*The location of pain will also vary with both the above cases. In supraspinatus tendonitis, the patient will complain of pain above the spine of scapula upto the acromion.

While in bicipital tendonitis, the patient will complaint of pain upto the middle of arm.

*The strength of rotator cuff muscles is greatly reduced although the strengthening of scapula (serratus anterior, rhomboids, trapezius, latisimus dorsi) are unaffected.

*If the cause of impingement is calcium deposition. It will lead to tearing of rotator cuff muscles.

*In the presence of tear, instability of glenohumeral joint is present.

  

TREATMENT

The basic aim of the physiotherapy management is:-

 💧 to reduce pain

 💧 to improve extensibility of the thickened and contracted capsules of the joint.

 💧 to increase mobility of the shoulder

 💧 to improve strength of the muscles.

👉 To reduce pain- Electrotherapuetic modalities are used like U.S., IFT, TENS, LASER, CRYOTHERAPY, ETC.

👉 To increase mobility of the shoulder- When pain and effusion subsides, therapist can give mobilisation to the shoulder joint.

👉 To increase ROM- Active exercises upto pain free range ⇒ Active assisted exercises using WAND and PULLEY. 

👉 To improve strength of the muscles- Resisted exercises ( resistence should be increased in gradual manner.)

      

Thoracic Outlet Syndrome (Diagnostic tests with its management)

 

INTRODUCTION:- Thoracic outlet is the opening through which the thorax communicates with the root of neck. It is a group of disorder that occur when blood vessels or nerves in the space between clavicle and the first rib. It is the presence of neurological symptoms due to compression of :-

              i) brachial plexus
            ii) subclavian artery at the outlet of thoracic cage.

CAUSES:- 💧 Tight Scalene muscle
                   💧 can be associated with dislocation of clavicle.
                   💧 tight pectoralis minor muscle
                   💧 presence of cervical rib (extra rib) 
                   💧 adaptive shortening of fascia.
                   💧 faulty posture

DIAGNOSIS:- ADSON'S TEST-  In this test, the radial pulse is 1st palpated, then the shoulder of affected side is extended, abducted and externally rotated, if the radial pulse is vanish then the test is POSITIVE.

WRIGHT'S MANEUVRE- The patient after palpating his pulse is asked to abduct the shoulder to 90 degree, then externally rotated and go into 5-10 degrees hyperextension. If pulse is vanished, the test is POSITIVE.

ROOS TEST:- Also known as Elevated Arm Stress Test (EAST). The patient's shoulder should be abducted to 90 degrees, externally rotated with elbow flexed to 90 degrees. Ask the patient to open and close the hands for 3 minutes. The patient will not be able to do that., then the test is POSITIVE.

CLINICAL FEATURES:- The patient will feel pain, tingling, numbness in hand along the ulner nerve distribution. There will be difficulty in performing overhead activities repeatedly especially involving external rotation. There will be weakness in the grip of the hand in advance cases especially the precision part.

MANAGEMENT:-  Inter-cervical traction for 10 minutes. U.S. is applied in between the clavicle and scapula. To reduce pain IFT or TENS is given along the course of nerve. ULTT3 is also tried alongwith stretching of scalene, pectoralis minor. Exercise of hands to improve hand function

PAINFUL ARC TEST

  -: PAINFUL ARC TEST:-

Purpose of Test-  To test for the presence of subacromial impingement.

Test Position- Sitting or Standing

Performing the Test-  In this, the patient is asked to elevate (either flexion or abduction) the arm. The test is considered POSITIVE if the patient has pain in between 60-120 degrees of the movement.

Role of Physiotherapy in Rehabilitation

 The aim of rehabilitation is "to take the patient from the bed to the job." To achieve this, a large team-organisation is necessary and as a member of this team physiotherapist plays a very important role. The requirements of the physiotherapist or any other member of the team to achieve the great result are:-

   👉 the ability to carry out instructions accurately.

   👉 the ability and desire to cooperate with the other members of the team, especially with occupational therapist.

  👉 observe accurately for evaluation and in the planning for the disabled.

  👉 ability to give the patient confidence.

Physiotherapists play a role in:-

      💧 PREVENTION 

      💧 TREATMENT

      💧 RESTORATIVE

                                  1. PREVENTIVE ROLE

Assess the physical health and identifying any musculoskeletal, neurological problems that could be aggravated by any means.

To carry out awareness programme in various communities, regions by conducting camps, audio-video tapes, banners with the help of local people or the local resource providers.

To identify the higher risk population and to plan a strategy to overcome that problem.

To arrange meaningful workshops on small scale in different regions or communities to make people aware about general health, hygiene, use of services provided by government.

To plan workshops, focusing mainly on the old age population in the region making the family members aware about the problems that could be face by affected persons. Example: high risk of fall, etc.

To plan workshops to check the risk on pediatric problems in a region.

To prevent any secondary complication of the bedridden patient or patient who are admitted in ICU and cannot move like bedsores, retention of lung secretion, oedema, muscular atrophy.

                            2. TREATMENT ROLE

Physiotherapist advises some exercises to the patient to achieve therapeutic benefit and these exercises are called Therapeutic Exercises.

Coordination exercises- any patient who is not able to do a purposeful movement due to lack of coordination.

Balance training- balance can be improved by Frankel Exercises 

Management of spasticity- by passive stretching of agonist and strengthening of antagonist. Splints and positioning are also done.

Relaxation exercises- deep breathing, etc

Reeducation of muscles with the help of electrotherapeutic modalities like faradic current.

Strengthening exercises- by applying resistance in gradual manner.

Treatment of scars and adhesions.

To treat the pain by different electrical modalities like TENS, U.S., IFT, etc.

          3. RESTORATIVE ROLE

In this phase, occupational therapist plays an important role.

Help in getting the individual independent in doing his ADLs.

Make him master of some activities so he can earn for himself.

Help him in gaining self-confidence.

Help him to get out of any depression or low self esteem.

Teach the patient to avoid such factors which can relapse the conditions

Gait training- to make the patient independent 

SYRINGOMYELIA

                                                       

                                                                      INTRODUCTION

Syringomyelia is a term derived from Greek word. 'Syrinx' means tube or cavity and 'myelos' means spinal cord. Hence it is characterised by elongated cavities lining close to the central canal surrounded by glia. These are often extended upwards to the medulla leading to syringobulbia. 

                                                                  ETIOLOGY

1. CONGENITAL:- In this, there is malformation of the cerebellum which protrude out from its original position to the cervical or neck portion of the spinal cord.

2. ACQUIRED:- Due to trauma, meningitis, hemorrhage, tumour. Here the cyst is formed in spinal cord by one of these cause.

                                                                  PATHOLOGY

CSF serves to cushion the brain. Excessive CSF in the central canal of the spinal cord dissects into the surrounding white matter and form a cystic cavity or syrinx.

The usual age of onset is 25-40 years but it may be as early as 10 years and as late as 60 years.

                                                             SIGN AND SYMPTOMS

Most characteristic symptoms are Anaesthetia i.e. loss of sensation of pain and temperature, but not of touch, vibration or motor. This is due to uninvolvement of posterior column until late.

Muscular atrophy and paralysis occurs as soon as anterior horn cells are subjective to pressure.

The patient usually notices slow onset of wasting and weakness of one hand which may be progress upward upto the trunk.

Feet are also involved but later.

DTR(deep tendon reflexes) are diminished or lost.

Analgesia and thermoanaesthetia have segmental distribution involving 1st ulner side, then radial side and then neck and chest.

Occular paralysis leading to ptosis and smaller pupil.

In severe or chronic cases, ataxia or spastic paraplegia is also seen.

                                                                    SYRINGOBULBIA

👉  Involvement of medulla also

👉  nystagmus present

👉  vertigo present

 👉 motor function of cranial nerve may also be seen.

                                                            TREATMENT

Surgery is the treatment of syringomyelia. Physiotherapy treatment is same as we do for a spinal cord injury patient. We will improve muscle power, patient education, frankel exercises for balance, prevt secondary complications, etc.

                                                                        

TRIGEMINAL NEURALGIA | PHYSIOTHERAPY MANAGEMENT IN TRIGEMINAL NEURALGIA

                                                      INTRODUCTION

It is a facial pain syndrome which is characterised by short term, unilateral facial pain following the sensory distribution of cranial nerve V, the Trigeminal nerve. Most commonly, the pain radiates to the mandibular or maxillary regions.

                                                  CLINICAL ANATOMY

The trigeminal nerve, the 5th cranial nerve, is the nerve responsible for sensation in the face, and control of motor functions such as biting and chewing.                                                                                              It has three branches:-  

                        i) Opthalmic nerve (V1) - It is sensory nerve receive sensation from the forehead. 

                      ii) Maxillay nerve (V2) - It is again sensory which takes sensation from the maxillary                                                                             region.

                     iii) Mandibular (V3) - It is sensory and motor both, controlling the muscles of                                                                                   mastication: Temporalis and Masseter.

                                              MECHANISM OF INJURY

The symptoms of pain is usually caused by compression of the Trigeminal nerve route in CNS. The common cause of compression can be tumor or their associated blood vessels. It can be due to the complication of Multiple Sclerosis and neurological conditions, due to demyelination of the root entry of Trigeminal nerve in the pons.

                                            CLINICAL FEATURES

The pain can come in sharp spasms that feel like electric shocks. Pin generally occurs on one side of the face and may be brought on by sound or touch. Pain can be triggered by brushing teeth, shaving, putting on makeup, touching face, eating or drinking, speaking, etc. 60% of patients with TN present with lacinating pain shooting from the corner of the mouth to the angle of jaw.

                                                  DIAGNOSIS

There is no need for any particular diagnosis, as the patient with characteristic history and normal neurological examination may conclude the disease. MRI scanning is often indicated simply to exclude the other causes of the pain, such as Acoustic Neuroma.

                                          DIFFERENTIAL DIAGNOSIS

✔ Atypical facial pain

✔ migraine

✔ Cluster headache

                                                MANAGEMENT

Antiepileptic drugs are very useful in management of TN. Some patient require surgery if condition worsens over time and drug management becomes less effective. Microvascular decompression and radiofrequency thermorhizotomy are the surgical procedure.

                                         PHYSIOTHERAPY MANAGEMENT

The main goal of physiotherapy are:-

                       ✔ to relieve symptoms

                       ✔ to restore functions                                                                        

                        ✔ to reduce the pain in face and other affected areas

Patient were treated with continues TENS for 20 minutes over the path of the affected nerves for 5 days a week for 4 weeks. One electrode was placed just before the ear, the other one at end of the respective nerve.

To reduce muscle spasm, a hot moist pack was applied on neck and trapezius muscle for 10 minutes, Isometric exercises for each side and pain free neck range of motion exercises (neck flexion, extension, side-flexion) for five repetitions each are given.

Relaxation exercises which includes deep breathing exercises should be performed for 10 minutes. 

Distraction techniques are also incorporated, patient are asked to involve in those activities in which they like to perform instead of sitting and thinking of the pain situations.

To reduce hypersensitivity, patient were asked to cover the affected side of their face with the soft cloth or with the cotton pad for 15 minutes per day, which may help in promoting a reduction of the nervous system to constant afferent input.

Finally, the patient is asked to avoid use of cold water for drinking and washing their face, use of a scarf to avoid the exposure of the face to the cold environment and to avoid eating hard food and chewing food on the non-affected side.

PARKINSON'S DISEASE ( SYMPTOMS, ASSESSMENT, CAUSES,) PARKINSON-PLUS SYNDROME

 INRODUCTION:- It is a progressive disorder of the CNS with both motor and non-motor symptoms. The onset is gradual, basically after 50 years. The cause is disturbance in the Dopamine system in basal ganglia. A dopamine deficiency can be due to a drop in the amount of dopamine made by the body or due to reduction of receptors in the brain.

SYMPTOMS:- MOTOR SYMPTOMS include the cardinal features of rigidity, bradykinesia, tremors, and, in later stages postural instability, muscle weakness, festinating gait, etc.

              NON-MOTOR SYMPTOMS include sensory symptoms, dysphagia, speech disorder, cognitive dysfunction, depression and anxiety, autonomic dysfunction, sleep disorders.

ASSESSMENT:- 

COGNITION:- It examines the memory, orientation, conceptual reasoning, problem solving, judgement. A brief screen of cognitive function can be obtained using MMSE (Mini-Mental Status Examination).

PSYCHOLOGICAL FUNCTION:- It determines the level of depression, stress anxiety, insomnia, anorexia, sadness. All these symptoms should be asked to the patient. Instruments like- Geriatric Depression Scale and Beck Depression Inventory.

VISUAL FUNCTION:- It determines acuity, light and dark adaptation, and accomodation. Patient will experience blurring of vision and difficulty in reading which is not improved by corrective lens.

MOTOR FUNCTION:- A) RIGIDITY- Initially there is asymmetrical rigidity which affects shoulder and neck later affects trunk and extremities. In this, there is determination of type of rigidity whether the rigidity is sustained( lead pipe) or intermittent (cogwheel). 

  B) BRADYKINESIA- Initially movements are slow, and in later stages, movement become arrhythmic with frequent start hesitation and arrests(akinesia). A stopwatch can be used to count the movement time and reaction time (elapsed time between the patients desire to move and the actual movement response). Timed tests for Rapid Alternating Movements (RAM) can be used to determine the effects of bradykinesia.

C) TREMORS- The location, persistence and severity of tremors should be recorded. Upper limb functional skills such as drinking from a cup, feeding, dressing and writing can be used to test for the effects of tremors.

D) POSTURAL CONTROL- The therapist first observe the patients resting posture in sitting and standing which further changes with movement.

E) BALANCE- Berg Balance Scale (BBS)                                                                                                                          - Functional Reach Test (FRT)                                                                                                                      -Timed Up and Go Test (TUG)                                                                                                                      -Cognitive Timed Up and Go (CTUG)                                                                                                          -Dynamic Gait Index (DGI)

F) GAIT- Assess all parameters and characteristics of gait during walking on level surface include start time or gait initiation, speed of walking, stride length, etc.                                                                                       - 6-minute walking test

CARDIOPULMONARY FUNCTION- In this, pulmonary function test, breathing pattern, chest wall mobility and thoracic expansion are checked. Along with these, vital signs like B.P., Respiratory rate, etc are also assessed. 6- or 12- minute walk test can be used to determine endurance capacity. Treadmill, cycle ergometer (arm or leg) are also used.

DISEASE SPECIFIC MEASURES- Parkinson's Disease Questionnaire (PDQ-39) is a 39-item questionnaire. It focuses on eight health-related quality-of-life dimensions (mobility,ADLs, emotional well-being, stigma, social support, cognition, communication and bodily discomfort).